Diagnosing for Status & Money
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Is the DSM scientific, political, social control, or simply for profit? Opening Statement By Ofer Zur, Ph.D. In principle, mental health diagnoses can be helpful to clinicians and researchers in their formulation of treatment, research, and communication with other professionals. Unfortunately, the DSM has been shaped by economic and political influences rather than by scientific and medical ones. The DSM assigns diagnoses in a biased manner, resulting in more harm than good to our patients, their families, and society at large while delivering huge profits to pharmaceutical companies. Women, children, minorities, lower income, and older people are the groups most likely to be negatively affected by the biases presented in the DSM. DSM Recap:
DSM pathologizes many normal and healthy behaviors Shyness: You are mentally ill if you are very introverted or extremely shy. Grief: God forbid if you intensely grieve the loss of a beloved one for more than six months. Depression: You must be mentally ill if you respond to real life issues or injustices with deep sadness and intense despair. Anxiety: You must be mentally ill if your reaction to the existential reality of mortality or loneliness involves profound or debilitating anxiety. Lack of sexual interest: Lack of sexual interest is often not a mental disorder. Many women may have good reasons to avoid sex. Spirited children: DSM casts a very broad net around ADHD, and often includes millions of spirited, strong-willed, and highly gifted and creative children. Online Article: DSM: Diagnosing for Status and Money
Jacob Mack pending M.S. Forensic/Clinica wrote:
Thank you for this post. I am a graduate student who has taken extensive courses in interpeting and applying the DSM-IV. I must concede that despite many claims to the contrary, the basis of ICD-9 for insurance purposes has ruined clinical diagnostic assessment as it is distorted by corporate one size fits all classification. I like having a multi axial system, but human behavior and thought processes are far more complex than such a limited biopsychosocial model can account for or function in terms of predictive value.
07/04/10 23:00:23
Helen T. Whitley, LCSW wrote:
Thank you for this forum. I am a licensed clinical social worker in private practice full-time. I am also proud to say I am a Certified Laughter Yoga Teacher. I train mental health professionals and others to be Certified Laughter Yoga Leaders. Laughter has only recently been given the credit it is due, and the new med and disorder being proposed is likely to scare people away from the thousands of free laughter clubs that exist worldwide. There is an expanding body of research on the NUMEROUS health benefits of laughter. Those benefits are markedly increased when laughing in a group for 20 minutes, interspersed with deep, yogic breathing. It is aerobic and social activity at its finest. So many of us agree that the DSM is mostly a sham supported by big pharma. RE: the new pill for "emotional incontinence" for controlling uncontrollable laughter is going to pathologize laughter (THE best medicine) to the point that people are going to be worried about laughing too much.
11/27/09 12:37:00
Elizabeth Miller, grad stdt, Clin MH Cnl wrote:
Regarding the disease model and trauma assessment/Dx/treatment: I wonder if the same diagnostic approach were used in physical medicine, would the diagnosis for a broken leg be "Broken Leg Syndrome" or "Somatic Fibular Pain Disease"? Instead of looking for the cause of the pain, would the patient be given medicine to manage or mute the symptoms and be told to stay on the meds and "make the best of things"?
Would the patient be asked to diagnose himself or herself with a question such as "Is your leg broken?" (Compare with the lone question SOMETIMES included in psych evals: "Have you ever been abused?", vs. including appropriate questions/items to detect probable trauma). I work with complex trauma and dissociation, where I find many clients whose psychic pain reaction to psychological (and other) wounding is commonly pathologized, and often medicated down with strong pharma-cocktails that can mute their somatic and affective cries of pain (i.e., their trauma reactions). (To clarify: I am not speaking out against appropriate psychopharmacology, but against pathologizing a pain reaction.) We KNOW that a high percentage (e.g., over 70% of multiple-admission female mental unit patients) report childhood abuse, yet we do not appropriately screen or treat. How can we call this ethical?
11/19/09 19:38:09
Brad Beebe, Ph.D. wrote:
There are some settings and consumer groups for whom the DSM system's utility more or less outweighs the drawbacks. However, even these best of circumstances for the utility of this diagnostic system itself, an additional problem is that there are no necessary qualifications for the people who "make" these diagnoses, and from what I have seen first-hand, diagnoses often are ascribed by people who have no more expertise than a simple ulterior motive. Since the DSM system is likely going to be around for awhile, I propose that there be a multidiscplinary board to oversee a certification in DSM diagnoses, and certified diagnosticians can therefor be recognized as meeting minimal requirements. Then, you would at least be able to argue whether or not certified (implying qualified) diagnoses are an imporovement in reliability, if not external validity.
10/26/09 11:27:13
thomas scheff wrote:
In my work I have treated what is called mental illness as a vast variety of deviant acts (rule breaking) for which there is no vernacular tag: crime, drunkeness, selfishness, etc. In this scheme, the DSM is virtually meaningless.
Most of my fellow sociologists have accepted this idea, but most psychiatrists don't get it.
10/21/09 20:17:33
Julianne Sobel, Psy.D. wrote:
There might be value in this medication and diagnosis of emotional incontinence secondary to a neurological condition e.g. pseudobulbar palsy or post-stroke emotional incontinence. Person's who are unable to stop laughing or crying often feel very embarrassed and fear being seen by other's as socially inappropriate.
10/20/09 23:09:46
Tedd Judd, PhD, ABPP-CN wrote:
I don't want to detract from your criticism of the pharmacological influence on DSM one bit--I think you are right on target. But as a neuropsychologist I do want to inform your readers that laughing or crying too much in a way that does not correspond to the internal feeling state that the person appears to be expressing is no laughing matter. It is a fairly common consequence of stroke and sometimes other neurologic disorders. The crying is more common and more socially disabling, but the laughing can be problematic if it is severe enough. Fortunately, most of the time it can be dealt with quite effectively through education and some simple control techniques, and most of those with the condition prefer them. But there are a few people where the condition is so severe that they prefer a pill, as well. These are individuals who can barely converse because laughing and crying continually interrupt.
The problem here, of course, is that that limited legitimate medication use becomes the camel's nose under the tent. Big pharma will barge on in. I have always hated the term "emotional incontinence" for this condition. It's demeaning. I have preferred "reflex laughing" and "reflex crying." They emphasize the neurologic nature of the disorder and the disconnect of emotional expression from emotional state. That being said, I find the idea of medicating someone for laughing too much in the absence of a clear neurological cause to be repulsive.
10/20/09 21:57:57
Edahn wrote:
Pills to make people laugh less? LOL
If there are people who really are laughing when it's not socially appropriate, how about talking to them and helping them feel less guilty, or teaching them ways to explain to others that they are just more prone to giggling? The DSM needs to be revised by someone with greater insight and less avarice.
10/20/09 20:47:23
Nola Nordmarken, MA wrote:
Yes! Yes!!, Azzia Zur. One big laugher here...ready for work.
10/10/09 08:00:02
Azzia Zur, B.A. Philosophy wrote:
Now big laughers and feelers are pathologized:
http://irnewsservice.com/ge... Can I have the laughter disorder please? We should send big laughers to the children's cancer wards to cheer up patients, not medicate the laughter. "Labile affect or pseudobulbar affect refers to the pathological expression of laughter, crying, or smiling." What do do? "Treatment for labile affect is usually pharmacological . . ." These are just feelings, folks. We should spend more time helping TV, consumer, internet, food addicts come into their bodies and emotions than medicating the emotions out of expressive people. Unless we're trying for 1984. . .
10/09/09 12:22:17
Gerald Drucker, Ph.D. wrote:
The first step in a science is an agreed upon tazonomy. By this standard we have to agree that psychiatric diagnosis has yet to reach the first step, as it has been shown with DSM-III and DSM-IV that diagnoses cannot be assigned, even in the best of situations,in a reliable fashion: field trials of the DSMs failed to meet scientific standards of reliability. They were not even close. Weren't we taught in graduate school that if something is not reliable, it cannot be a valid tool. Oh, and then we get to the large psychotherapy outcome literature, especially meta-analytic studies and studies that pit one type of therapy against another. They show that neither diagnosis nor the theoretical approach of the therapist increases therapeutic efficacy. The best predictors of the variance in psychotherapeutic outcome are 1) client characteristics and 2) the quality of the working alliance. Irv Yalom, in his book Lying on the Couch (a work of fiction and a wonderful read for anyone) has one of his protagonists posit that one practically has to invent a new approach to psychotherapy for each and every client. If one accepts what the outcome studies seem to be telling us (not to mention our own experiences as psychotherapists) then the most important variable we control in our work is the quality of the working alliance, and that requires tailoring our approach to the individual or family in front of us. Diagnosis does not help with this.
09/24/09 09:53:13
Leelind Gee, LMFT wrote:
I have always had difficulties with the DSM. As a culturally sensitive therapist in No. Cal I find that many of the diagnoses are pathological for many, even with the supposed cultural awarenes. I believe and I share this with my clients, that I don't really believe in Dx and that it is only helpful to know what we are dealing with and for insurance purposes. I have ct's ask me to include diangosis on invoices for services they have privately paid for and this is challenging because many times it just doesn't apply.
Many times I have had minorities families from different countries tell me, you know this just doesn't exist in my country. They are not denying the experience, but they are denying the lable it has and that it needs some special medication. Besides, as you pointed out, people will respond in normal fashions of sadness, anxiety and anger to situations. Isn't it our job to help them through it rather than just put the bandage on it and hope for the best. It kills me that vcodes are not paid for by insurances, because they are seen as not medically necessary. What does that mean? If someone is having problems with their partner and they have physical symtpoms, what do we treat, the relationship or the symptoms?
09/23/09 11:06:22
Lee Myerhoff, Ph.D. wrote:
We in community mental health are held hostage by the medical model and the DSM. We bring mental health professionals and their training to the least treated groups- elderly, homeless, homebound. In order to provide this service, we must use the DSM and the medical model. That is unless we are independently wealthy. No DSM, no medical model, no pay for our service to these needy groups. We make that decision for ourselves (and our trainees) every day. We also put out the word about the inadequacy of the DSM and the medical model for mental illness treatment.
09/22/09 10:36:53
Azzia Zur wrote:
Asexuals are the latest group to seek an end to the pathologizing of 'another way of being' in the world:
http://www.sfgate.com/cgi-b... The goal of this group is to be removed as a disorder from the upcoming DSM V (2012).
08/24/09 21:12:29
Samantha Nelson wrote:
I also believe the DSM labels are damaging to clients, especially victims of abuse, as they begin to feel there is no hope for them once a label has been given them. Some will use that as an excuse to never attempt to get well or heal. As a Christian, I have also seen miracles where, no matter what label was given, the client has been healed through prayer. The DSM is just a way to make money and keep people sick, in my opinion.
08/20/09 09:03:05
Syed Imam, PhD wrote:
I wholly agree with Dr. Zur, we should get together to subdue the medical model in the therapeutic outcome, when different psycho therapeutic techniques have been found to be more effective than these psychotropics. labeling itself creates a curse on once life and predisposition and what DSM propagate is to assign a label before he/she would get any tangible intervention. This health care mafia controlled by the insurance mafioso is ruining and milking the system in a very systematic and acceptable fashion. We need to rise against these acceptable unethical practice and stick to the old school. Pharmaceutical companies are reaping the best harvest by diagnosing even the children and making their fortune at the cost of others life and existence. This is terrible business of making money out of once penury.
God bless us all. Syed Imam, PhD
08/19/09 23:41:32
Marty Saeman, Managing Editor wrote:
This is an interesting debate which has gone on for years. Psychologists and others have wondered about a new diagnostic system for some time (as much as 20 years or more). When the Psychodynamic Diagnostic Manual (PDM) came along in 2006, some thought that was the answer. It too has problems. "While each revision of the DSM was developed by reviewing thousands of studies, research for the PDM is by comparison, scant at best." (Kapalka, 2009 The National Psychologist Sept/Oct 2009 in press). Others began working on non-medical classification systems but to no avail. Rather than dismissing the DSM as a product of psychiatry (ApA) and "Big Pharma", why not seek to work cooperatively with them to develop a multidisciplinary diagnostic system which all mental health professions can embrace?
Marty Saeman, Managing Editor The National Psychologist http://www.nationalpsycholo...
08/19/09 15:19:21
Gerald Vest wrote:
These DSM labels are not healthy, respectful or responsible to and with our clients/patients. Our professions should join together and eliminate the DSM from our health and education programs. If we value science we will insist that there has to be reliabiliy and validity in our inquiry and investigation. Also, several months ago, one of the leaders in the APA stated that we don't know what a "Disorder" is. We will have to find a definition that is accurate.
08/19/09 13:35:04
George A. Noriega, M.Ed. wrote:
I'm one of those clinicians who has a love hate relationship with the DSM. My job requires that I put a label on every child and teenager I see. Sometimes this makes me feel uncomfortable because I'm really thinking this is nothing more than a normal reaction and behavior. That being the case, I use the "Phase of Life Problem" code nevertheless because the job requires it.
08/19/09 09:11:13
David Cohen wrote:
Any multi-level obstacle for the proper understanding of persons in their real-life circumstances--as the DSM surely is--must be addressed at all levels, wherever one happens to be at the moment. It's the "Think globally, act locally" adage. With one's clients, one should never miss an opportunity to express one's disagreement with an invalid diagnostic system that places distress in the realm of medical pathology without a single biological marker used to make a single diagnosis of a "primary mental disorder." One should encourage clients to discuss and formulate their own explanations of distress. With one's third-party payers, one must register one's disagreement that the DSM has no scientific validation and request to know what the payers are doing to wean themselves from it. With one's students and colleagues, one must circulate the dozens of analyses, from all helping professions, that express despair at what the DSM has wrought. With the media, one must repeat that the DSM has brought cultural, professional, and economic changes, but no scientific understanding whatsoever of human distress and misbehavior. And one must think about and plan how we must not give up our own independent professional assessments simply to pay our bills. In the past, slaves in much worst situations than therapists today revolted and overthrew their oppressors. Visualize how you wish to practice, and get there! Otherwise, how can we possibly expect our clients to overcome their own difficulties?
08/19/09 08:20:01
Michael D. Williams, MFT wrote:
I cannot disagree with any of the statements below...but what does one do about it?
I've appreciated that I was largely able to stay out of the DSM fray while in private practice in California; I simply did very little 3rd-party payee work and avoided it for the most part. But interfacing with any government or 3rd party requires it. Sometimes I feel as if I'm participating in a scam. I take every opportunity to explain it to my clients, referring physicians, etc. so none of us has mistaken expectations of the "diagnosis". But I'd like to go further than that. Obviously I'll never be an influencial member of the APA--or even a nomimal member. Any ideas of what we can do?
08/19/09 06:32:13
John A. Riolo, PhD wrote:
Mental health professionals seem to have a love hate relationship to DSM. Many of us don’t consider it to be clinically useful. Nevertheless we use. Why? It gives us access to third party payment from insurance companies. To separate money from medical insurance companies we do need to pathologizes many normal and healthy behaviors. We can’t just put the blame on pig pharma. The rest of are no better.
The problem is that while we may think of DSM as little more than a billing code to get money, the insurance companies , courts, attorneys, employers etc. accept the meaning of these codes as if we meant it. This means that if we give a patient a diagnosis of say, Major Depression because we know that is sure to be reimbursed that diagnosis could come back to haunt the patient in many ways for years. It’s a problem in the diagnosis were accurate but all the more so if it were not. If we don’t believe in DSM we should not use it even if it means it will cost us money. John Riolo, Ph.D. http://www.youradvocateonli... & http://insider.libsyn.com
08/19/09 04:22:15
Garry Cooper, LCSW wrote:
The DSM has so little relevance for treatment that one has to ask what its use is, aside from insurance coding--which also has little relevance for actual treatment. Perhaps its last chance for treatment relevance was to be found in the ultimately futile efforts to find the most empirically supported treatments for specific disorders--an effort that's seeming more and more futile as it begins to look like there are common factors to many successful treatments which cut across diagnoses. Once committed to a faulty premise--in this case that disorders can be neatly split and categorized--it's human nature, I suppose, to persevere and keep trying to adjust in order to justify the faulty premise, rather than to junk the premise and scrap the entire project. The Psychodynamic Diagnostic Manual (PDM), by looking at disorders on continuums and looking at them from a clinical, rather than behavioral, perspective, and in part from the client's perspective, follows a much more clinically relevant set of assumptions.
Garry Cooper, LCSW Contributing editor of Psychotherapy Networker magazine
08/13/09 22:13:02
Tom Smith, Ph.D. wrote:
The DSM has transmogrified over the years from a good will effort to bring some order to diagnoses into a profit maker for the psychopharm industry and can increasingly be used by family members or the social order to control certain individuals for nefarious purposes. This will probably continue as discoveries are made in the neurosciences that open up more opportunities for the pharmaceutical industry to medicate both normal and troublesome behavior or symptoms. Just who is working on the current version and who is getting paid? This sounds cynical, but "follow the money". It is like the military industrial complex that Eisenhower warned us about. Things are now out of control of the practitioner. We are now at best subject to the DSM and at worst, its slave.
08/13/09 10:36:57
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